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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1196373 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- A O l Inspection Type(Fill one) <br /> 0 Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S���vp� p �1 (� 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �)M w5& Sufpl� <br /> Physical Addreist e5 W- -7 o <br /> sem. r) <br /> M Q,C w ( J <br /> 533 ] Inspection Date I0. C1 <br /> Time In Time Out <br /> Business Rep Title O 0 O AM 3 O� O AM <br /> 11 <br /> KU�L� l"1 G'iu. 0 PM 0 PM <br /> �C'C 'r (-t Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' d• ® Active Q Passenger ®Generator 0 Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude — Q Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 In Compliance-No Violations o <br /> O O Other:§ <br /> Commentson` q t ��.a Oq) J <br /> Inspection Form Included: 01AM <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspe r s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: FTXTA 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop':L © ■ <br />